FULL CONSULTATION DOCUMENT Proposed changes to the way Mental Health Services are delivered in the Western Isles

FULL CONSULTATION DOCUMENT Proposed changes to the way Mental Health Services are delivered in the Western Isles Your chance to comment on proposals This document provides full information about the consultation on proposals to modernise Mental Health Services in the Western Isles. It also provides details on how you can feed back any comments, suggestions or observations on these proposals. The best at what we do 1

Contents 1. Introduction Page 3 2. Purpose of Consultation Document Page 4 3. Drivers for Change Page 4-6 4. Public Consultation Process Page 6-7 5. Involvement and Engagement Processes Page 7-9 6. Preferred Option Page 10-11 7. Impact on Patients Page 11-13 8. Workforce Implications Page 13-14 9. Finance Page 14 10. Health and Social Care Integration Page 15 11. What Happens Next Page 15 12. Appendix (Financial Assumptions) Page 16 Comments on all aspects of our proposals are welcome by Friday 30 th August 2013. You can write to: Lillian Crichton Mental Health Service Consultation NHS Western Isles 37 South Beach Stornoway Isle of Lewis HS1 2BB Alternatively, email Lillian.crichton@nhs.net Please note that this document is available in a larger font on request. 2

1. Introduction 1.1 Modern Mental Health Services have increasingly become more patient centred and recovery focused. Essentially, what this means is ensuring that patients are more actively involved in their own individual care, treatment and decisions, with support provided to enable them to stay in their own home or community, where possible. This is possible through a focus on their personal recovery and supporting them to manage their own individual condition, assisted by professional teams made up of workers with different skills and expertise. 1.2 NHS Western Isles is aware that there is a need to change the way we deliver our services to ensure that a service such as this is provided, and that patients and clients are receiving the most appropriate care at the right time, in the right place. 1.3 The reason for change is based on an understanding that the way services are currently delivered within the Western Isles does not allow for an effective, locally delivered, patient centred approach to providing Mental Health Services. Modern community based services consist of teams of practitioners, including specialist nurses and doctors together with support workers, who often work closely with Local Authority and Third Sector colleagues, to deliver effective, integrated, locally based care. The way we currently provide services does not allow us to develop such teams because our capacity and staffing is largely based within Western Isles Hospital in Stornoway. 1.4 The current service model in the Western Isles falls some way short of delivering a modern approach to Mental Health Service provision, the national NHS Healthcare Quality Ambitions (see Section 3) and the Mental Health Strategy for Scotland 2012-2015 (see Section 3). At present, most of our Mental Health Services are based in Western Isles Hospital in Stornoway, where there are: sixteen old age psychiatry inpatient beds (Clisham Ward) five acute psychiatry inpatient beds (Acute Psychiatric Unit). 1.5 Services are provided in the community setting by the Adult Community Psychiatric Nursing Team. Additional services include: the Child and Adolescent Mental Health Service; an Alcohol Liaison Service; a Mental Health Occupational Therapy Service; and Learning Disability Services. Invaluable Mental Health Services are also provided in the community setting by Third (voluntary) Sector partners. 1.6 Considerable work has been progressed over the past six years to scope Mental Health Services in the Western Isles and to develop a variety of options for future services which better meet the needs of patients, and are safe, effective, sustainable and affordable. 3

2. Purpose of Consultation Document 2.1 Following on from engagement and scoping exercises (described in Section 4), NHS Western Isles considered a number of options for the redesign of Mental Health Services in the Western Isles. These options were: Option 1 Option 2 Option 3 (PREFERRED OPTION) Minimal Change Option Northern Island Model Enhanced Community Model No change in model of service - (Orkney and Shetland) Option 3 would create an continue with current No inpatient beds locally. increase in community capacity arrangements and staffing Acute psychiatry patients by partial disinvestment in model. requiring admission referred to inpatient facilities. This could be 5 bed acute inpatient unit. mainland facilities (mirroring done in a number of ways, 16 bed psychiatry of old age other island board service including changing the current unit. No change in current configuration of Community Service provision. provision). Challenging behaviour unit for dementia patients provided in the community. Redeployment of staff from the two inpatient facilities to a single unit, with a reduced number of beds, for both adult and old age psychiatry. hospital setting to the community would increase community capacity and skill mix. 2.2 NHS Western Isles is now consulting on its preferred option Option 3, which will involve the retention of an appropriate number of inpatient beds and a redeployment of resources into community-based services. 2.3 This document provides more detail about the preferred option and describes: Drivers for change (Section 3) Public Consultation Process (Section 4) Involvement and Engagement processes (Section 5) Preferred Option (Section 6) Impact on patients (Section 7) Workforce (Section 8) Finance (Section 9) Health and Social Care Integration (Section 10) What happens next (Section 11) 3. Drivers for Change 3.1 NHS Western Isles has identified that Mental Health Service provision needs to change to meet the varying needs of the population, to deliver services that are based on evidence, and also to meet current national requirements. 3.2 We are focused on the modernisation of services for adults with Mental Health problems, and on the need to provide local support within the community to reduce the likelihood of individuals needing hospital care. However, where inpatient care is needed, it must be provided in 4

appropriate surroundings (a therapeutic environment) by staff with the required skills and competencies. 3.3 Modern approaches to treatment for mental illness have improved outcomes for clients, as services have become more community focused. In the Western Isles, there has been a steady reduction in hospital based services but without an increased capacity to manage patients with more complex care needs in the community. This has resulted in NHS Western Isles having the longest length of stay in hospital of all Health Boards and the highest readmission (to hospital) rates of all island boards. This is the outcome of a system that has focused more on reactive inpatient care and less on both anticipatory (preventative) care and recovery. 3.4 Gaps in the current service model include: Capacity/skill mix in community services; liaison psychiatry service (support offered to medical/nursing staff to carry out psychiatric assessments); specific dual diagnostic support (where people have more than one mental health condition); limited specific dementia support; and limited psychological therapy provision. 3.5 NHS Western Isles is committed to ensuring that the needs of individuals and their carers are at the centre of any redesigned service. Their experiences, views on the quality of care and treatment and access to information and services formed the basis of our whole approach to these developments and continue to be the key drivers for change. 3.6 In developing plans for modernising Mental Health Services in the Western Isles, the overarching strategic framework is the NHS Healthcare Quality Strategy (see http://www.scotland.gov.uk/resource/doc/311667/0098354.pdf). The six dimensions within the Quality Strategy have each been considered and have been used as a guideline for mapping discussions around service change. The six dimensions ensure that our plans are: Person-Centred - Our engagement with stakeholders (service users, partners, staff, etc) has been clearly focused on what is best for the individual service user and their carers. Working with patients and carers to develop mutually beneficial partnerships is central to an effective relationship and the development of patient-centred services. Safe - Systems and processes to protect patients from avoidable harm are fundamental to any service redesign. Clear policies and procedures that protect patients from harm need to be built into the new service model. Effective - The design of effective, evidence-based service delivery, learning from best practice elsewhere, but incorporating unique island factors, is a challenge that we understand. Efficient - Value for money, particularly in the current financial climate, is crucial. Furthermore, modern working practices, using technology where appropriate, are to be adopted. Equitable - Fairness and equity of provision are central to our aspirations and are a key driver for change, requiring us to consider how we best move away from our traditional model of care. Timely - Improving access, both reducing waiting times and bringing care closer to patients, is an essential outcome of a redesigned service. 5

3.7 With regard to national drivers, the Framework for Mental Health Services in Scotland (available at www.show.scot.nhs.uk/publications/mental_health_services/mhs/index.htm), published in 1997, set out in detail the wide range of services which should be available to take forward service modernisation and increase community provision. This is supported by the Mental Health (Scotland) Act 2003 ( see www.scotland.gov.uk/resource/doc/26487/0013533.pdf for further information) which requires the least restrictive option of care; that is, allowing people, as far as possible, to be treated in their own homes, affording them more freedom. 3.8 The NHSScotland 2020 vision states that, by 2020, everyone is able to live healthier lives at home, or in a homely setting. This focus on anticipatory care and improved self management is consistent with the recently published Mental Health Strategy for Scotland 2012 2015 (http://www.scotland.gov.uk/resource/0039/00398762.pdf), which focuses on seven themes. The Seven Themes for Mental Health are as follows, and it is the view of NHS Western Isles that these areas would be more effectively addressed and achieved under Option 3: 1. Working more effectively with families and carers. 2. Embedding more peer to peer work and support. 3. Increasing the support for self management and self help approaches. 4. Extending the anti-stigma agenda forward to include further work on discrimination. 5. Focusing on the rights of those with mental illness. 6. Developing the outcomes approach to include personal, social and clinical outcomes. 7. Ensuring that we use new technology effectively as a mechanism for providing information and delivering evidence based services. 4. Public Consultation Process 4.1 Public Consultation about our proposals was launched on 13 th May 2013 and is due to end on 30 th August 2013. The additional time over the three month required period reflects the acknowledgement that this consultation will include some time when some stakeholders may be on leave. 4.2 A leaflet summarising the proposals and the information contained within this document is available. If you would like a copy of this, you can either download it from the NHS Western Isles website www.wihb.scot.nhs.uk or you can call 01851 708064 during normal working hours for a copy to be posted out to you. 4.3 NHS Western Isles will also be hosting Open Public Meetings for service users, carers and the public to obtain information or submit points of view. There will also be the opportunity during these meetings to meet with NHS staff to discuss the proposals. If you would be interested in finding out more about these sessions, please contact Lillian Crichton on 01851 708064 or at lillian.crichton@nhs.net. Similarly, if you or your group would like to discuss anything with us about the consultation or Mental Health Services, please let us know and we will do our best to accommodate your request. 6

Consultation Process Begins - Monday 13th May 2013 Public Consultation Events (to register for any of the events below, please contact Lillian Crichton on 01851 708041 or at Lillian.crichton@nhs.net) Barra & Vatersay Event Castlebay Community Hall, Wednesday 5 June at 7pm North/South Uist & Benbecula Event Dark Island Hotel, Benbecula, Thursday 6 June at 1pm Lewis & Harris Event Garry Room, Caladh Inn, Stornoway, Tuesday 18 June at 7pm Third Sector Event Garry Room, Caladh Inn, Stornoway, Wednesday 19 June at 7pm There will also be a range of events with staff who will be closely involved in this process. A specific part of the process will be established to ensure consultation with Comhairle nan Eilean Siar and local Housing representatives. Consultation Ends Friday August 30th 2013 4.4 Staff meetings and briefings will also be organised and staff will be notified of these directly. 4.5 Comments on all aspects of our proposals are welcome by Friday 30 th August 2013. You can write to: Lillian Crichton Mental Health Service Consultation NHS Western Isles 37 South Beach Stornoway Isle of Lewis HS1 2BB Alternatively, email Lillian.crichton@nhs.net CONSULTATION SUBMISSIONS MUST BE RECEIVED NO LATER THAN Friday 30 th August 2013. 5. Involvement and Engagement Processes (Background Information) 5.1 In February 2010, the Scottish Government issued guidance on Informing, Engaging and Consulting People in Developing Health and Community Care Services. The guidance aims to ensure a consistent and robust approach is adopted when Health Boards consider and propose new services or any changes to existing services. 5.2 Staff from NHS Western Isles have worked with the Scottish Health Council to date to develop a process that facilitates the participation of a range of clinical and non-clinical individuals and groups in the discussions concerning the future of Mental Health Services in the Western Isles. 5.3 A Communications and Engagement Plan was developed with input from the Scottish Health Council, which sets out the Board s objectives for the Mental Health modernisation process, in 7

terms of communication and engagement, and describes key actions to ensure activities are effective. 5.4 The programme of engagement has sought to: Build relationships with interested groups; Ensure that patient and carer input is considered in all aspects of the process; Ensure effective Patient Participation, so that patients are encouraged to take part in decisions about their health and wellbeing, through engagement in service modernisation, in line with the Patient Rights (Scotland) Act 2011; and Ensure that all aspects of engagement are conducted in an open, inclusive, sensitive and values-based manner. 5.5 From 2004, various initiatives to scope Mental Health Services in the Western Isles and develop recommendations for improvement, have taken place. 5.6 Following on from a service-wide Service Redesign exercise in which local services were scoped and evaluated, considerable data was gathered during an engagement phase as part of the Clinical Strategy Se Ur Beatha engagement and consultation process between 2007 and 2009. 5.7 The Clinical Strategy consultation and engagement process focused heavily on Mental Health Service modernisation, and a significant number of public meetings, staff meetings and meetings with other partners and interested parties (e.g. local councillors, MP/MSP, Third Sector organisations) were held over a period of years to listen to the aspirations and experiences of different stakeholders, to share trends in how healthcare systems were developing across Scotland, and to discuss how Mental Health Services could be adapted locally to better reflect the needs of patients. 5.8 As the Clinical Strategy consultation work progressed, a separate but related area of work was taken forward from April 2008 December 2009, to scope Mental Health Services for older adults in the Western Isles and develop a vision for future services, known as Proiseact a Chliseim. 5.9 Considerable consultation and engagement with service providers (NHS and Third Sector) and service users was undertaken to develop a vision for future Mental Health Services for older adults which was subsequently detailed in the document, A Vision for Mental Health Services for Older Adults in the Western Isles The Clisham Report. 5.10 A future model of care is defined within the Clisham Report and some key early deliverables (changes that have already taken place) have been progressed as a result of this work. This includes the development of a Clisham Memory Garden for the residents of Clisham Ward and an external audit of Clisham Ward. 5.11 An external Review of Mental Health Services in the Western Isles report, known as the Watt Report, followed on from the Clinical Strategy work during 2009. The report, compiled following consultation with key stakeholders, focuses on one of the key areas raised by the public and staff during the Clinical Strategy consultation period shifting the balance of care from a predominantly hospital-based model to a more community-focused model. Also fundamental to the modernisation of services identified in the Watt Report is better use of telecommunications in line with the Board s vision to become a leader in the application of telehealth. 8

5.12 All the above engagement exercises have involved service users, carers, and Third Sector organisations, and they have each contributed to the array of documents and ideas that have been considered as part of the current Mental Health Service modernisation process. 5.13 With regard to more recent involvement of key stakeholders, a number of engagement meetings were held to ensure the ideas gathered and documented through previous processes were still valid. A wide range of meetings were held with different staff groups and community teams. The paper The Clinical Strategy s vision for NHS Western Isles Mental Health Services was used as a template to prompt discussion and measure current thinking. This paper was also circulated to Locality Planning Groups, local Council members, Clinical Advisory Committees and both of the Mental Health and Learning Disability Partnerships. The views of the Local Authority and Third Sector were obtained through the Mental Health and Learning Disabilities Integrated Planning Group. The Scottish Health Council was asked to advise on the process throughout. 5.14 The formal Option Appraisal process took place in January 2012, led by the Medical Director. This involved a series of three meetings across the Western Isles (Lewis, Uist and Barra). Key stakeholders were invited to attend these meetings. 5.15 Government guidance has been carefully followed at each stage of the engagement process. The guidance is clear in stating that patients, carers and the public can play an important role in the assessment of non-financial costs and benefits in options for service change. It advises that financial issues should be considered separately from the non-financial benefits of any service change. As such, whilst the need to provide cost effective services was clear, financial aspects were considered separately to the Option Appraisal process. 5.16 A Mental Health Options Appraisal Short Life Working Group was established comprising NHS stakeholders and service users. The group was supported by Scottish Health Council representation. This group determined the initial list of Benefits Criteria, which were developed from feedback from service users, carers and staff. These are listed below. The group also produced a Participant Pack, which outlined the process for the Options Appraisal. Benefits Criteria: Retain local services and prevent avoidable travel Prevention, recovery and rehabilitation Promote access to services closer to where people live, including crisis response Increased capacity to a range of community services Development of care pathways with mainland health boards Improvements around admission and discharge arrangements More use of technology 5.17 Circulated to participants prior to the Options Appraisal events, the Mental Health Options Paper and various accompanying documents set out the background on the need for change, the current services and the options for service redesign, which have emerged from the processes of engagement with public, professionals and other interested groups. 5.18 A summary of the three options was presented by Dr James Ward (Medical Director) at the Option Appraisal events. Advocacy staff and staff from the Third Sector were available to support service users present at the events. The Benefits Criteria were discussed by participants and there was also an opportunity to amend or propose different criteria. This allowed for the consideration of distinct demographics and geographical issues. 9

5.19 Following a process to agree the criteria, the group weighted each criterion, based on its relative importance, and subsequently scored each option against the weighted criteria. 5.20 Analysis of the Option Appraisal demonstrated that Option 3, the Enhanced Community Model, was preferred by Lewis & Harris and Uist participants. Barra participants preferred Option 2, perhaps reflecting their remoteness from existing acute services. No group preferred the continuation of the status quo (Option 1). 6. Preferred Option Option 3 (Enhanced Community Model) 6.1 This section contains our preferred option and why we consider this to be the best option for Mental Health Services in the Western Isles. 6.2 We invite stakeholders, as part of this consultation, to comment on our proposal, our conclusions on the other options, and whether they consider that there are other viable options that have not been considered. Feedback from this consultation process will be reported to the Board to enable Board members to make a fully informed decision. 6.3 In recommending a preferred option, the following issues have been considered: The Option Appraisal process involving staff, patients/carers and other stakeholders produced an overall preferred option Option 3. The status quo (Option 1) does not allow for an effective, modern, locally delivered approach to Mental Health Service provision. Within the current model (Option 1) there is a lack of community capacity, and hospital resources need to be freed up to enable investment into the community. Under Option 2, a small number of acutely ill patients would have to travel to the mainland for inpatient care. Under Option 3, inpatient facilities for acutely ill patients would be retained locally, but partial disinvestment in facilities would enable investment in the community. All models allow for key developments, such as improved use of technology and stronger links with mainland services. Option 1 goes against national directives which are intended to improve care. 6.4 The pros and cons of each option were also considered in full at Option Appraisal meetings (see below): OPTION 1 Minimal Change Pros No change Maintain familiar make up of inpatient services Cons Outdated model of service No recovery focus Resources concentrated around the hospital, rather than in the community Lack of community capacity Creates a culture of dependency, reducing self resilience Avoidable admissions and protracted lengths of stay Not what staff, service users or key partners have told us they would like to see delivered The status quo would continue an outdated model of care with the emphasis on hospital care; no capacity would be released to address the gaps in current service provision, which have been clearly outlined earlier in this document. 10

OPTION 2 - Northern Island Model (Orkney and Shetland) Pros Disinvest in inpatient facilities Increase community capacity through inpatient staff redeployment allowing for intensive home treatment and psychological therapy provision Reduce inappropriate admissions Highlights recovery model Allows for increased use of information technology Cons Small number of acutely ill patients requiring to travel to access inpatient facilities, with resultant logistical problems for patients and their relatives. Require support of a larger Health Board to run all of our inpatient provision. OPTION 3 Enhanced Community Model Pros Inpatient facilities for acutely ill patients retained Partial disinvestment in facilities, to shift balance of care from hospital to community Increase community capacity through inpatient staff redeployment allowing for intensive home treatment and psychological therapy provision Reduce inappropriate admissions and shorter lengths of stay Allows for increased use of information technology More modern service configuration against which to implement local Dementia Strategy Cons Patient mix may provide challenges to building design. Less ability to redeploy staff than Option 2. 6.5 Following a lengthy process of stakeholder engagement and formal Option Appraisal regarding non financial benefits, it was the view of the great majority of those involved that Option 3 represented the preferred direction of travel. 7. Impact on Patients How many beds are we likely to need in the future? 7.1 One in four people will experience a mental health problem at some point in their life. Most people will receive informal support, rather than accessing NHS or local authority services. A small proportion of people will receive psychiatric care in the community, and an even smaller proportion will require to be admitted to hospital. In Scotland overall, there has been a downward trend over recent years in the number of people who are admitted to hospital. 7.2 It is not best practice for the majority of people who have traditionally been admitted to hospital with dementia to be in a psychiatric facility in hospital. The aim would be to provide improved care at home and single room accommodation within a new single unit, in line with best practice, for patients who may be more dependent. 7.3 Ultimately, the best place for people with dementia is in their own homes, with appropriate support in place for them. The Dementia Standards support this, and remaining part of the community allows a person to function better than they would in a care home. With increasing capacity in the community, there would be more staff to work with and support people with dementia and their carers in the community. 11

Projections 7.4 In considering our bed numbers we can split this in to Acute Adult Psychiatric Beds for those who require inpatient care and beds for patients with Dementia who exhibit the most challenging behaviours. 7.5 Dementia. Demographic predictions show that, by 2023, the population of the Western Isles will be 25,252 and there will be approximately 727 people who will have a diagnosis of Dementia. This represents 2.9% of the population. It is estimated that 1% of people who have a diagnosis of dementia will require to be hospitalised because of challenging behaviours. This will mean NHS Western Isles will require around 7 beds for people who have dementia and who present with challenging behaviours. 7.6 Acute Adult Psychiatric Provision. Acute Adult Psychiatric Care is often provided by services within mainland partner Boards. There are a large range of services that we will not be able to provide locally under any circumstances and we will continue to depend on specialist services in other boards. Including; ICPU (Intensive Care Psychiatric Unit provision) ECT (Electro Convulsive Therapy) Patients with eating disorders who require admission People with serious mental health problems in the peri-natal period (associated with pregnancy and childbirth) Forensic Mental Health provision. Including low, medium and high secure provision (patients with mental health problems that bring them in contact with the police and courts) Residential services for people with Learning Disabilities and associated Mental Health problems. Specialist recovery and rehabilitation services. 7.7 With these services provided off island, it makes it difficult to predict the number of acute psychiatric beds required for the Western Isles by comparing us with other Boards. In considering this we have therefore determined that it would be unwise to assume a bed utilisation less than the status quo (5 acute psychiatric beds); however we do know that we have relatively poorly developed community services and the second highest readmission rates compared to elsewhere in Scotland. It is the intention of NHS Western Isles to continue to provide 5 acute psychiatric beds, anticipating that, with enhanced community support, we may well not require this number in the future. 7.8 The combined bed compliment (12) could be provided in a single unit. The bed capacity could be used flexibly and inter-changeably, according to the needs of inpatients and would allow staff to be redeployed into the community to provide the enhanced level of care, closer to home that we wish to see. The transfer of ward based staff into the community would provide a range of services that would be aimed at reducing the length of patients stay in hospital, reducing readmission rates, and reducing inappropriate admissions to hospital. 7.9 People with Learning Disabilities have a higher risk of experiencing mental ill health than the general population, and provision for meeting the needs of this group within our population is a priority for Mental Health Service modernisation. The development of the new model of service delivery will take account of people with a Learning Disability and their particular needs for 12

interventions in the community and when there is a need to access inpatient services. Further work will be undertaken to define what those needs are and to incorporate these into service planning. 7.10 The final design and configuration of a Community Mental Health team remains to be shaped by this consultation exercise; defined, costed, agreed and implemented. There are already in place a range of effective models across NHS Scotland. 7.11 Under Option 3, patients would access services closer to where they live, and have access to specialist care and advice in the community more quickly. Equity of provision and access to services will be central to any changes. 7.12 Access to a place of safety will not change regardless of which option is chosen. This will continue to be in the designated areas in Western Isles Hospital, St Brendan s and Uist and Barra Hospital. 8. Workforce 8.1 Graph 1: Current Mental Health Staffing Model, which shows the percentage of staff based in the hospital, the percentage based in a community setting, and the percentage that work across both areas. Under Option 3, by shifting the balance of care from hospital to community, more staff would be based within a community setting, with fewer numbers being based in the hospital. Graph 2: Potential staffing model under Option 3, with a 12-bed inpatient service and enhanced community service. 13

8.2 Key staff organisations have been involved in the development of options to date and will continue to be involved as this work progresses. The full implications for staff will be discussed with them individually and will include partnership and professional representatives where appropriate. The NHS Western Isles Organisational Change Policy will apply and the overarching principle in managing staffing changes will be the security of employment for existing staff. Staff will be managed in accordance with their NHS terms and conditions which, at present, guard against compulsory redundancy. 8.3 Under Option 3, a hospital workforce in proportion with the bed configuration is envisaged. Community Mental Health teams will be established. These teams would be based in local communities and work closely with existing services, GPs, Third Sector, Local Authority, etc. The skill mix in the teams would allow the Community Psychiatric Nurse Team Leaders more time to spend with those in greatest need and offer appropriate, locally delivered care. 8.4 Consultant input would be retained, as would the local option for admission to hospital if this was deemed to be clinically required. 9. Finance 9.1 Any new mental health service model must be deliverable within the current cost envelope. The current cost envelope based on the 2013/14 budgets for those Mental Health Services under review is as follows; community psychiatric nursing (CPN), acute nursing, and mental health Occupational Therapy, all totalling 1,716,196. This figure excludes; mental health acute placements on the mainland, community mental health placements and psychiatrists. It should be noted that this budget will continue, along with the rest of the Board s budgets, to be subject to financial efficiency savings targets which will be set during the budget setting process each year. 9.2 National benchmarking data, however, indicates that there could be opportunities to design and manage a more efficient service, as our rates of admission and lengths of stay are significantly above national averages. Therefore, in the medium to long term, a redesigned service will be able to set robust efficiency objectives, contributing to the Board s ability to invest in new service priorities. 9.3 An indication of current spend and an illustration of how this is expected to vary under option 3 is shown in the table below: Budget NHS Direct Costs Year 1 Year 2 Year 3 '000 '000 '000 '000 1,662 Nursing Costs 1,880 1,548 1,408 54 Other Direct Costs 206 296 308 1,716 Total Cost 2,086 1,844 1,716 Budget Available 1,716 1,716 1,716 Surplus/(shortfall) (370) (128) 0 It should be noted that many assumptions have been made in arriving at the figures shown. The key assumptions are shown in Appendix 1. The table above shows a prudent position, and illustrates that during the transition to the new model there could be significant excess costs. A key assumption is that staff due to be transferred to the community will do so all together on day one, and these staff will need to be fully back-filled at the hospital well into year 2. It is more likely that the transition from the hospital setting to the community would be a phased process to minimise disruption, which would mean that any additional backfill costs could be managed at a lower level and this will become clear as the detail of the model is refined. In any case, the figures show that by year 3 the service should be operating within the cost envelope. 14

9.4 A full workforce appraisal will need to be undertaken and it will be this workforce plan that will influence the final costing for the new service model. The financial data shown above excludes any partner or stakeholder costs and any required capital funding for enhancements of the ward areas. It is expected that capital funding will be required in year 2 and an appropriate bid will be developed. 10. Health and Social Care Integration 10.1 During the period that NHS Western Isles has been reviewing Mental Health services, there has been a refocusing nationally on how best to provide integrated services for people in the community. 10.2 Health Boards and Local Authorities are actively discussing how their services can be more joined up to ensure that service users receive seamless care and that those partner organisations providing this care work together to best effect. 10.3 Some people with Mental Health problems already benefit from the interventions of health and social care workers, as well as input from the Third (voluntary) sector and sometimes from private providers. 10.4 It is our intention to ensure that opportunities for better integrated working are considered and captured as part of this consultation process. To that end, in addition to public and staff consultation events, there will be specific consultation meetings between Health and Local Authority colleagues and a specific event for Third Sector / Voluntary agencies. 11. What happens next? Once we have received comments from all interested parties by August 30 th 2013, we will carefully review all we have been told. Our aim is to take the final proposal to Western Isles Health Board later in 2013. The proposal will contain details of the Public Consultation process and a full summary of comments received during the consultation period. The outcome of the Board s subsequent discussions and decision will be communicated widely. 15

Appendix 1: Financial Assumptions Staffing General 1. Pay and Budget are all shown at 2012/13 prices and all posts are costed at the top of the grade to reflect the current position. 2. Pay protection has been assumed for affected staff. 3. Allowances, including those for nights and weekends, will be protected for all staff including U&B. 4. For the first year any vacancies will be filled by bank/temporary staff. Dual Running 5. The completion of the patient transfer into the community could take at least 3 years and therefore there would be a requirement for dual running within this period. The 3 year period is based on a number of assumptions, principally: the inpatient unit remains within the hospital; and the work required is detailed in the capital programme, funding is available in the next financial year and the requisite work is undertaken by end of the third year. 6. All staff due to be transferred to the community will do so all together on day 1. These staff will need to be back-filled at the hospital until bed numbers reduce. This represents the highest cost scenario. 7. In the first year the staffing requirement will not reduce sufficiently to change the staffing levels in the acute setting. During the second year there will be a gradual reduction and by the end of year two there will be no need for backfill for staff transferred to the community. 8. The final staff redeployment will take place in the third year. By the end of this year the staffing numbers will represent the projected workforce for option 3. Displacement of Staff and new Posts 9. Costs include the Mental Health OT, staff to deliver CBT and a Dementia Nurse Consultant. General 10. Travel costs have been estimated based on an average cost in 2012/13 of 4,300 per CPN. 11. All non pay costs other than training will remain static regardless of where the care is provided. To note 12. Figures do not include increased depreciation resulting from any interior works required and do not reflect the cost of any disruption which may be caused whilst any works are undertaken. 16